AMA: Revisions, clarity needed before physicians form Medicare ACOs

There is said to be an old Chinese curse: May you live in interesting times. As I wrap up my year traveling the country as President of the AMA, I can without a doubt say physicians are living – and practicing medicine – in interesting times. This can be a challenge, but does not need to be a curse.

There are many changes underway in our profession that can be daunting to physicians already struggling to manage a busy medical practice. The AMA strives to be a resource for physicians, advocating to policymakers on behalf of the profession and providing the information physicians need to keep the changes in these ‘interesting times’ from becoming overwhelming.

One important role of the AMA is to provide input to government agencies as they form the regulations that govern the practice of medicine in our country. During the current implementation phase of the Affordable Care Act this work is more critical than ever.

In the past two weeks, the AMA has submitted comments to CMS, OIG, FTC and DOJ on their proposals regarding the governance of Medicare accountable care organizations (ACOs). The proposed rule on ACOs from CMS alone was over 400 pages in length and covered a wide range of issues. These complex documents lay the groundwork for the creation of this new health care delivery model, but still leave significant concerns that must be addressed before physicians can be expected to take the leap into forming ACOs.

The AMA supports testing ACOs as one of an array of payment and delivery innovations. We believe that, if well-developed, they have the potential to improve the quality and coordination of patient care while increasing the value of health care spending. But the FTC, DOJ and CMS need to make significant changes to the proposed rules to allow all interested physicians to lead and participate in these new delivery models.

Forming an ACO requires significant resources for physicians and may involve major changes to their practice. CMS must allow those who take this risk to fully share in the benefits from day one. The AMA called for numerous changes to the proposed payment and risk structure of ACOs to encourage participation by physicians in all practice sizes. This includes a payment option that allows all ACOs to receive a percentage of savings achieved, but does not require them to take the risk of a financial loss that could deter smaller groups in particular.

The AMA has stated that existing antitrust rules can make becoming part of an ACO difficult for physicians, especially those in small practices. As proposed, the FTC and DOJ policy on ACOs simply does not go far enough to level the playing field, leaving small physician practices at a disadvantage compared to hospitals and large insurance companies. Clarification and modifications are necessary to ensure physicians in all practice sizes can form an ACO.

If ACOs are to be successful the requirements placed on them cannot be overly burdensome. The AMA has urged CMS to reduce the mandatory percentage of primary care physicians in an ACO who must use electronic health records (EHRs) by the second year. The proposed level of 50 percent of primary care physicians using EHRs is simply unrealistic given the complexity and cost of transitioning to these systems. The AMA also recommended changes to reporting requirements, including allowing ACOs to report on the quality measures that are most relevant to their patient population.

Patients are critical to the success of these new delivery models. Just as involvement in ACOs must be voluntary for physicians, ACOs should also only include patients who are interested in participating. The AMA made several recommendations to CMS related to patients, including allowing physicians to know upfront which patients are in their ACO.

ACOs have the potential to improve care coordination and quality while promoting cost savings, but they can only succeed if properly implemented – and flexibility will be key. In addition to the numerous changes that we already know must be made, the AMA has asked CMS to issue an interim, instead of a final rule, on ACOs. This will allow them to adapt their policies as needed during this initial phase, rather than locking in regulations that could hinder success in the long run.

Not all physicians will become part of this new delivery model, but those who are interested must be able to see a clear path to forming an ACO. The AMA will continue to be a voice for physicians on this and other payment and delivery innovations that are being shaped during this interesting time.